Hospital pharmacy in Germany

There are now 80 million inhabitants in Germany. To serve this population there are about 2,200 hospitals, categorised into primary care, secondary care, tertiary care and psychiatric hospitals. Hospitals can be publicly owned, affiliated to a church or partly privately run. The rate of occupancy is higher than 80%, and the number of hospitals and hospital beds and the average duration of stay are continuously decreasing (see Table 1).

[[HPE07_table1_86]]

Before January 2003 there were different types of reimbursement for hospital stays in Germany. The traditional “rate of care” included the total costs of care for a patient per day and was negotiated between the hospital administration and the sickness funds. Different hospitals and often different wards in the same hospital charged different fees. It was not to the hospital’s disadvantage if the patient stayed longer. In fact the first days of a hospital stay are the most expensive, so it didn’t make financial sense to discharge patients too early.

As of January 2003 inpatient costs are reimbursed according to a diagnosis-related group (DRG) system. Prices are now fixed according to the diagnosis and are paid to the hospital for all inpatients, with the exception of psychiatric patients. This is a so-called “fourth-generation” DRG system, which takes into account comorbidities and the complexity of a case. From an economic point of view, the shorter the stay in hospital, the better for the hospital.

Two-thirds of hospital expenditure goes on personnel and one-third on nonpersonnel costs; 50% of the nonpersonnel costs are for medicinal supplies (which, in addition to drugs, include all medical devices, blood products and implants). Drug costs alone comprise just 3–4% of total hospital costs.

German hospital pharmacy system
A hospital may establish its own hospital pharmacy, establish a supply contract with another hospital pharmacy, or establish a supply contract with a retail pharmacy (see Table 2). Hospital pharmacies supply 80% of hospital beds and are owned by the hospital. The director of the pharmacy department reports either to the managing director or the medical director of the hospital.

[[HPE07_table2_86]]

Hospital pharmacy in Germany is usually responsible for three main areas of drug therapy:

Pharmaceutical logistics.

Drug manufacturing.

Clinical pharmacy services.

Today most hospital pharmacies, especially the larger ones, are organised according to these responsibilities. Clinical pharmacy services were introduced into practice during the last decade and are to be increased in the future.

Almost all pharmacists working in hospitals do a postgraduate specialisation. They have to work for three years in an authorised hospital pharmacy, attend seminars and pass an oral exam. After their studies they acquire the title “clinical pharmacist”. This postgraduate course is the responsibility of the “chamber” – the regionally organised council of pharmacists, to which all pharmacists must belong, which serves in an administrative and regulatory capacity.

The German Society of Hospital Pharmacists represents the interests of hospital pharmacies in the healthcare system, and 80% of all hospital pharmacists are members. The society initiates further professional development and continuing education.
Pharmaceutical logistics and formulary management
Pharmaceutical logistics encompasses all services which guarantee that the right drugs and medical products are available at the right time and quality for the right patient. It includes proper ordering, receipt, storage and distribution of medicinal supplies. Drugs to be stocked are usually regulated by the hospital formulary, which is demanded by pharmacy law and controlled by the drug committee. Pharmacists often chair the drug committee. Formulary management involves deciding between therapeutically equivalent drug therapies according to efficacy, safety and cost.

Hospital pharmacies are involved in drug use reviews and budget control. Knowledge of pharmacoeconomics and promotion of cost-effective drug therapy is essential for pharmacy directors. Because of budget restrictions and the movement towards evidence-based medicine, the acceptance of treatment guidelines and consultant pharmacists is high.

Drugs listed in the formulary are stocked in the hospital pharmacy. Hospital pharmacies buy the drugs directly from the pharmaceutical industry. This is the only free drug market in Germany. Prices are negotiated between the pharmaceutical industry and hospital pharmacists. Purchasing discounts are supposed to reduce the financial burden on the hospital. Today almost all hospital pharmacies use computerised inventory management systems.

Clinical pharmacy services
By definition clinical pharmacy promotes the safe, effective and appropriate use of drugs. There has recently been a change in focus from product handling to patient care.

Clinical pharmacy and pharmaceutical care in Germany originated in the hospital pharmacy setting. Clinical pharmacy was first included in the university curriculum in 2001. The course teaches optimisation of drug use on and by the patient. Topics covered include special drug therapies and criteria for the evaluation of drug therapies, risk–benefit assessment and health economics. There are already hospital pharmacists giving lectures in clinical pharmacy, and their role as teacher practitioners will expand. In my opinion, the combination of pharmaceutical practice, teaching and research is essential for teaching clinical pharmacy.

Contact between hospital pharmacists and prescribing doctors and patients is intensified by the provision of clinical services. Various services are established or currently under development in German hospital pharmacies. The clinical services on offer should be based on the focus and needs of the hospital.

Evaluation of treatment guidelines for nausea and vomiting, mucositis, fever of unknown origin, and so on.

Provision of extravasation kits, including guidelines to treat extravasation.

Evaluation and minimisation of incompatibilities in multidrug infusion schemes.

Clinical consultations.

By fulfilling these tasks the oncology pharmacist becomes an integral member of the cancer care team.

CIVA preparation service
The total parenteral nutrition (TPN) and central intravenous additive (CIVA) preparation service monitors TPN and drug prescriptions.

Pharmacokinetic service
A number of hospital pharmacists have established functioning pharmacokinetic services. However, drug level analysis is seldom performed in the hospital pharmacy. More often the pharmacokinetic consultations are done by pharmacists. Normally, drugs with a narrow therapeutic spectrum are the focus of drug level analysis (eg, aminoglycosides, antiepileptic drugs, theophylline and cardiac drugs).

Drug information service
Drug information services are established in many hospital pharmacies. Within the hospital, drug information is provided to all professionals, especially physicians and nurses, as well as to patients. Pharmacists specialising in the provision of drug information need to be familiar with the use of print and nonprint media. In our pharmacy department we use DrugDex and International Pharmaceutical abstracts (IPAs) on CD-ROM, as well as internet databases.

A number of hospital pharmacies also provide drug information to community pharmacies. The service is established by contract with the pharmacy chamber, and hospitals are paid for this service by the chamber.

Clinical rounds
Clinical pharmacists must be in touch with the patients and physicians. Therefore it is very useful to participate in clinical rounds, to learn about the problems of drug therapy, and to find solutions to these problems. The pharmacist monitors drug therapy (eg, the selection of drugs, formulations, dosages, administration route) and counsels doctors and nurses. Typical subjects covered in pharmacy consultations are:

Change from intravenous to oral administration.

Adjusting the dosage of a treatment.

Drug interactions.

Nonformulary prescriptions.

However, the participation of German hospital pharmacists in ward rounds is not comparable to the US practice. Because of the small number of hospital pharmacists, the service is targeted to wards with intensive drug therapy (eg, intensive care units and oncology units), or wards with increased need for drug therapy consultations (eg, surgery wards). In addition, the service is not necessarily offered on a daily basis.

Patient education and counselling
Clinical pharmacists are also involved in patient education and counselling. Some pharmacists take the drug history when patients are admitted and draw up a pharmaceutical care plan for the patient. There is one project in a German hospital where the nurses dispense the drugs, but a medication pharmacist provides the patients with drugs in the morning, giving them advice on how to take the drugs, informing the patients about the type of drug, indication and side-effects.

Some pharmacists educate patients about their drug therapy before they are discharged. For example, asthma patients are taught how to use their inhalers and diabetes patients their insulin pens.

Investigational drug service
The investigational drug service was recently established. Clinical studies are to be performed in accordance with the law, regulations and GCP rules. In order to improve adherence to these regulations pharmacists are more and more involved in clinical studies.

Services run by the pharmacy include drug storage, drug preparation in a blinded way, dispensing, record keeping, and return or disposal of unused drugs. If there is no pharmaceutical company involved as a sponsor, the pharmacy department is in charge of manufacturing the investigational drugs.

Conclusion
As budgets for human resources are restricted it will be difficult or impossible to increase pharmacy staff during the next few years. Therefore, if possible, tasks will be automated. Another challenge in German hospital pharmacies will be to find an efficient balance between pharmaceutical logistics, drug manufacturing and clinical pharmacy services. Knowledge and experience in each of these fields supports effective and efficient service delivery in the other two fields.

Hospital pharmacy promotes the safe and effective use of drugs in hospitals, by guaranteeing: